The Dental Patient with Somatoform Disorder: Diagnostic and Treatment Challenges in Occlusal Dysesthesia

The Dental Patient with Somatoform Disorder: Diagnostic and Treatment Challenges in Occlusal Dysesthesia John L. Reeves II, PhD, MSCP, ABPP1, 3 and Robert L. Merrill DDS, MS2 University of California at Los Angeles School of Dentistry Section of Oral Medicine and Orofacial Pain 10833 Le Conte Avenue Center for Health Sciences- 13-089C Los Angeles, CA 90095-1668 1Adjunct Professor, Behavioral Medicine Services Orofacial Pain Clinic 2Adjunct Professor, Director, Residency Training in Orofacial Pain Director, Orofacial Pain Clinic 3Address Reprint requests to Dr. Reeves The Dental Patient Somatoform Disorder John L. Reeves II and Robert L. Merrill Page 2 of 19 Men are disturbed not by things, but by the view which they take of them. Epictetus, 55-135 Aim: The aim of this chapter is to provide the dentist with an overview of potential diagnostic and treatment issues posed by patients who present with Somatoform Disorder. A patient with occlusal dysesthesia or “Phantom Bite” is presented to describe the challenges frequently encountered when attempting to diagnose and treat a patient with Somatization Disorder. Introduction: In dental practice one will encounter patients who are extremely focused, if not obsessed, with an orofacial complaint. The patient may complain of cosmetic concerns that seem imperceptible; of irrational fear of oral cancer in spite of negative physical findings, or they may present with a debilitating atypical pain, again without clear etiology. However, one of the most perplexing conditions is the patient who presents with occlusal dysesthesia (OD) also referred to as “Phantom Bite” 1. OD patients are preoccupied with their dental occlusion and convinced that their bite is off and abnormal 2, 3. The patient will be constantly checking their bite or attempting to reposition their jaw to find their bite. Frequently the complaints are long standing and can occur at any stage of dental care ranging from simple fillings to more extensive restorative procedures, orthodontics, or oral surgeries. Their perception of an abnormal occlusion persists despite repeated failed attempts to adjust the patient’s occlusion. No dental or pharmacological treatments have proven to be effective in reducing OD. Repeated failed treatments further reinforce the patient’s illness conviction that something is seriously wrong with their occlusion. When the dentist provides reassurances that nothing is wrong with their occlusion their distress escalates further. In an attempt to reassure the patient and reduce their distress and concerns, the dentist may refer the patient to an orofacial pain or TMD specialist for a second opinion. Though well intentioned, the referral may do the opposite and further increases the patent’s anxiety, somatic preoccupation and illness conviction. The patient misinterprets the referral as an indication that the dentist believes The Dental Patient Somatoform Disorder John L. Reeves II and Robert L. Merrill Page 3 of 19 the problem to be very serious and is providing a referral to a specialist to confirm the severity of the disease. Thus, these patients not only misinterpret physical sensations regarding their occlusion, but also most health related communications. OD patients are persistent in seeking multiple opinions and are frequently unreasonable in their demands for their problem to be “fixed.” The OD patient frequently presents with “tedious” verbal and written monologs chronicling the details of their dental problems and past treatment failures 3. They are invariably dissatisfied and angry with all of their dentists’ prior failures to resolve their occlusal complaints. Moreover, it is not unusual for these patients to be very litigious and want to “get back at” the dentists they perceive as having caused them harm. In spite of this they persist in looking for the “fix” and this eventually results in the patient falling victim to iatrogenic complications as a result of overly zealous attempts to accommodate the patient’s persuasive demands to “fix” their occlusion. The patient’s symptoms and lack of clear physical findings may appear to the dentist to be a relatively minor problem and certainly not warranting the degree of distress and disability being displayed by the patient. Further occlusal adjustments, splints, orthognathic, orthodontic or surgical interventions will not alleviate the OD but may even exacerbate the problem. Since no dental or neurological findings have been reported that can account for OD it is possible that these patients may, as a result of a psychological condition called Somatoform Disorder (SD), be somatizing that is, exhibiting severe somatic focus and mysterious occlusal complaints. Until the SD is addressed with psychological treatments, continued dental treatments will in all likelihood fail if not worsen the problem. What is SD? What is its etiology? What can be done to treat patients with SD? How do I tell a patient that I think their problem is mostly psychological and further dental treatment is uncalled for? This paper provides the dental practitioner with guidelines to address these questions. What is Somatoform Disorder? Patients presenting with OD frequently meet the criteria for Somatoform Disorder. They present with a history of excessive preoccupation with vague recurrent somatic complaints and specifically with a perception that their bite is not correct or “off” in the absence of collaborating dental/neurological evidence. This somatic focus and symptom The Dental Patient Somatoform Disorder John L. Reeves II and Robert L. Merrill Page 4 of 19 constellation is termed somatization and is the hallmark of the psychological disorder known as SD. The complaints are usually generalized but may have a single focus such as the patient’s bite or cosmetic concerns. More recent conceptualizations of somatization refer to it as health anxiety 4. When pathophysiology is present, the symptoms are in excess of what might be expected. The inexplicable complaints result in treatment seeking or doctor shopping and psychological, social and occupational impairment. Patients with SD incur healthcare expenses that are at least 6 to 14 times higher than the US average and result in enormous indirect economic costs due to lost work productivity 5, 6. Under the classification of SD, The Diagnostic and Statistical Manual- IV (DSM- IV) of the American Psychiatric Association (1994) 7 defines several categories of somatization disorders. Table 1 lists the different SDs. Table 1: Somatoform Disorders 1. Somatization Disorder: Historically referred to as hysteria, is a polysymptomatic disorder that begins before the age of 30 years, extends over a period of years and is characterized by a combination of pain, gastrointestinal, sexual and pseudo- neurological symptoms. 2. Undifferentiated Somatoform Disorder: Characterized by unexplained physical complaints lasting at least 6 months that do not exceed the threshold for the diagnosis of Somatization Disorder. 3. Conversion Disorder: Unexplained symptoms or deficits affecting the motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits. 4. Pain Disorder: Pain is the predominant focus of attention. Psychological factors are judged to have an important role in its onset, severity, exacerbation, or maintenance. 5. Hypochondriasis: Preoccupation with the fear of having, or the idea of having a serious disease based on a persons misunderstanding of bodily symptoms or bodily functions. 6. Body Dysmorphic Disorder: Preoccupation with an imagined or exaggerated defect in physical appearance. 7. Somatoform Disorder Not otherwise Specified: Any somatoform symptom not meeting the full criteria for the other specific Somatoform Disorders. Table 2 lists the general diagnostic features of SD as adapted from the DSM- IV. The Dental Patient Somatoform Disorder John L. Reeves II and Robert L. Merrill Page 5 of 19 Table 2: DSM-IV Diagnostic Criteria for Somatoform Disorder The DSM-IV lists several categories of Somatoform Disorders. The following summarizes the key features for diagnosing Somatoform Disorder: A) One or more physical complaints (e.g., fatigue, loss of appetite, GI distress, urinary complaints, pain). B) Either i or ii i. After appropriate investigation, the symptoms cannot be fully explained by a known medical condition or direct effects of a substance (e.g., drug abuse, a medication); ii. Where there is a related medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical or laboratory examination; C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D) The duration of the disturbance is at least 6 months. E) The disturbance is not better accounted for by another mental disorder (e.g., depression, anxiety, psychosis). F) The symptoms are not intentionally produced or feigned (i.e., malingering). In general dental practice, the incidence of patients presenting with somatization is 8.7% with women making up 73% of those meeting the criteria for somatization 8. Moreover, depression was found to be highly co-morbid with somatizing and this is consistent with other findings in the literature 9. Etiology of Somatoform Disorder: Dental and Neurological Theories: Dental and neurological explanations for OD that lead to effective treatments have been conspicuously

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